Peripheral Interventions in the VA Healthcare System Ehrin J. Armstrong MD MSc Director, Interventional Cardiology Denver VA Medical Center

Disclosures None relevant

Manifestations of Peripheral Artery Disease Lower Extremity Claudication Critical Limb Ischemia Acute Limb Ischemia Carotid Artery Stenosis Subclavian Artery Stenosis Renal Artery Stenosis Mesenteric Stenosis Abdominal Aortic Aneurysm Popliteal Artery Aneurysm

Estimates of PAD Prevalence Every patient in the VA! In a primary care population defined by age and common risk factors, the prevalence of PAD was approximately one in three patients NHANES1 Aged >40 years 4.3% San Diego2 Mean age 66 years 11.7% NHANES1 Aged 70 years 14.5% Rotterdam3 Aged >55 years 19.1% Diehm4 Aged 65 years 19.8% PARTNERS5 Aged >70 years, or 50–69 years with a history diabetes or smoking 29% PARTNERS trial showed us that many patients were not aware of the sx’s of PAD, and that routine screening, especially with ABIs can detect and treat these patients sooner. Prevalence of PAD Increases with Age 0% 5% 10% 15% 20% 25% 30% 35% NHANES=National Health and Nutrition Examination Study; PARTNERS=PAD Awareness, Risk, and Treatment: New Resources for Survival [program]. 1. Selvin E, Erlinger TP. Circulation. 2004;110:738-743. 2. Criqui MH, et al. Circulation. 1985;71:510-515. 3. Diehm C, et al. Atherosclerosis. 2004;172:95-105. 4. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192. 5. Hirsch AT, et al. JAMA. 2001;286:1317-1324. Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the national health and nutrition survey, 1999-2000. Circulation. 2004;110:738-743. Criqui MH, et al. The prevalence of peripheral arterial disease in a defined population. Circulation. 1985;71:510-515. Meijer WT, et al. Peripheral arterial disease in the elderly: the Rotterdam Study. Arterioscler Thromb Vasc Biol. 1998;18:185-192. Diehm C, et al. High prevalence of peripheral arterial disease and co-morbidity in 6880 primary care patients: cross-sectional study. Atherosclerosis. 2004;172:95–105. Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286:1317-1324. 4

PAD in Veterans 403 patients in Houston area over 50 years of age were screened with ABI. Prevalence was 13% among whites 22% among African Americans 14% among Hispanics Collins, Arch Int Med 2003

PAD and Survival Survival (%) Years Normal subjects Asymptomatic PAD 100 75 50 25 Normal subjects Survival (%) Asymptomatic PAD Symptomatic PAD Previous investigators have observed a doubling of the mortality rate among patients with intermittent claudication, and we have reported a fourfold increase in the overall mortality rate among subjects with large-vessel peripheral arterial disease, as diagnosed by noninvasive testing. In this study, we investigated the association of large-vessel peripheral arterial disease with rates of mortality from all cardiovascular diseases and from coronary heart disease. METHODS. We examined 565 men and women (average age, 66 years) for the presence of large-vessel peripheral arterial disease by means of two noninvasive techniques--measurement of segmental blood pressure and determination of flow velocity by Doppler ultrasound. We identified 67 subjects with the disease (11.9 percent), whom we followed prospectively for 10 years. RESULTS. Twenty-one of the 34 men (61.8 percent) and 11 of the 33 women (33.3 percent) with large-vessel peripheral arterial disease died during follow-up, as compared with 31 of the 183 men (16.9 percent) and 26 of the 225 women (11.6 percent) without evidence of peripheral arterial disease. After multivariate adjustment for age, sex, and other risk factors for cardiovascular disease, the relative risk of dying among subjects with large-vessel peripheral arterial disease as compared with those with no evidence of such disease was 3.1 (95 percent confidence interval, 1.9 to 4.9) for deaths from all causes, 5.9 (95 percent confidence interval, 3.0 to 11.4) for all deaths from cardiovascular disease, and 6.6 (95 percent confidence interval, 2.9 to 14.9) for deaths from coronary heart disease. The relative risk of death from causes other than cardiovascular disease was not significantly increased among the subjects with large-vessel peripheral arterial disease. After the exclusion of subjects who had a history of cardiovascular disease at base line, the relative risks among those with large-vessel peripheral arterial disease remained significantly elevated. Additional analyses revealed a 15-fold increase in rates of mortality due to cardiovascular disease and coronary heart disease among subjects with large-vessel peripheral arterial disease that was both severe and symptomatic. CONCLUSIONS. Patients with large-vessel peripheral arterial disease have a high risk of death from cardiovascular causes PAD is an equivalent to ischemic heart disease risk. The association between peripheral arterial disease and coronary artery disease has been known for many years Prevalence of CHD if history/physical exam is used 20%-40% Prevalence of CHD if noninvasive testing is used 50%-60% Prevalence of CHD if coronary arteriography is used ~90% Dormandy JA, and Murray GD. Eur J Vasc Surg. 1991;5(2):131-133. Severe symptomatic PAD 2 4 6 8 10 12 Years Criqui MH et al. N Engl J Med. 1992;326:381-386. 6

Vascular Medicine at Denver VA Claudication Critical Limb Ischemia Acute Limb Ischemia Carotid Artery Stenosis Subclavian Artery Stenosis Renal Artery Stenosis Mesenteric Ischemia Abdominal Aortic Aneurysm Popliteal Artery Aneurysm DVT/PE e.g., IVC filters Vasculitis Fibromuscular Dysplasia

What We Do Inpatient Consultation Outpatient Consultation About 2-3/week Outpatient Consultation Three clinics a week: see 40-50 patients weekly Dedicate vascular NP Vascular Noninvasive Studies One vascular tech 1600 studies/year Endovascular Procedures Mix of LE, carotid, and AAA interventions 350-400 cases/year

Placing an Outpatient Vascular Medicine Consult

Placing an Outpatient Vascular Medicine Consult

Ordering Vascular Lab Studies

Vascular Imaging Options

Arterial Imaging Examples

Case: Claudication 64M with PMH of prior smoking, hypercholesterolemia p/w calf pain on ambulation. Pain is bilateral, but left worse than right. Claudication begins at 100 yards, has to stop walking at 200 years. Tried a walking program x 6 months, but remains severely impaired in daily activities.

Follow-Up Patient went home later that day. No more claudication Have been following last 3.5 years – patent vessels, no symptoms.

Case: Critical Limb Ischemia 61 woman with ischemic rest pain and worsening necrotic ulcers on the medial and lateral aspect of the left lower leg CAD with h/o 2 vessel CABG in 2003 and recent stenting On hemodialysis No usable saphenous or arm vein

Arterial Ulcer

Follow Up No further rest pain. Ulcers healed. Duplex ultrasound: wide patency of popliteal artery stent, TP trunk, and peroneal artery.

Case: AAA 67M with 6.0 cm infrarenal AAA and severe R>L claudication. Concomitant R CIA aneurysm (30 mm). Occluded R EIA artery.

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Opportunities for Advancing the Care of Veterans with PAD More research on prevalence and outcomes of Veterans with PAD Optimal medical therapy Smoking cessation programs Integrated CART-peripheral Defined data elements Amputation prevention programs Centers of excellence? Multidisciplinary coordination